Compliance/PAM

As the Estates and Facilities services within a Trust are becoming increasingly judged by the CQC and Monitor on the basis of their PAM, ERIC and PLACE scores, it is becoming ever more important to ensure that these returns are completed in a timely, complete and consistent manner.

The new PAM Self-Assessment Questions (SAQs) are much more qualitative in nature and their completion requires broad experience across the spectrum of estates and facilities services – and beyond. For many Trusts, it may prove that this exercise looking at existing systems, documents, practices policies, perhaps developed in isolation, highlights that they no longer represent best practice or support a holistic model for the delivery of estates and facilities services aligned with the needs of patients, the Trust and other stakeholders.

Following requests from a number of our clients, GK Transformation are now pleased to offer a tailored service that can ensure that your PAM return is complete and accurate. Additionally, we can work with you to identify and address any areas for improvement before the return is finalised.

GK Transformation are now pleased to offer a THREE-TIER service that can ensure your PAM return is complete and accurate.

Bronze: PAM Preparedness Audit

We will work with you to define and locate the information sources necessary to complete the assessment spreadsheet. At first glance, the data requirements of the PAM Self-Assessment Questions (SAQs) may appear daunting. However, our analysis reveals that much of the information required should be readily available from existing documents and can be divided into three classes of sources:

1. Strategic

This defines the what, typically in terms of a number of requirements or objectives specified within one or more strategy or policy documents. We will identify whether such documents exist within the Trust and the degree to which they address the scope of the relevant PAM SAQs. This would typically include documents such as: • The Trust’s Strategic Plan • The Trust’s Estates (and Facilities) Strategy This work would also consider the softer and more holistic elements within the scope of the PAM assessment, such as: • The Trust context and external stakeholder interfaces • Estates & Facilities Capabilities & Competencies and their alignment with the wider Trust strategy and objectives • Appropriateness of Culture (Innovation, Openness, Flexibility, Learning & Development, Anti-Bullying, etc.) • Risk Management, including contingency modelling and up-to-date action plans • Economic (financial) sustainability

2. Tactical

This defines the how, usually in the form of procedure documents, containing sequences of activities and actions. We will review relevant Trust procedures to ascertain to whether they are of appropriate scope, detail and reference best practice in order to cover the PAM requirements. For example, ensuring that procedures both cover and refer to best practice models in: • Defined job roles and responsibilities • Health & Safety (possibly within a Trust-wide document) • Statutory and Best Practice Compliance (e.g. HCA & HACCP) • Adoption of applicable HTM and HBM standards • Performance Reporting and Improvement Mechanisms

3. Quantitative Measurements and Qualitative Assessments

This provides the who, when and where activity information; the evidence of how well the policies and procedures are functioning in practice. We will look for and itemise: audit reports, review findings, meeting minutes, outputs of automated systems, logs and other records of relevant activities which could be used to assess how well the PAM SAQ requirements are met both in terms of range and quality. For example, this would include: • Completeness, accuracy and timeliness of KPI reporting • Latest PLACE findings • ERIC return • Maintenance records and compliance with HTMs and HBNs • Condition surveys

Silver: Completion of the PAM SAQs

From the above, gap analysis will be used to identify those specific areas where the Organisation is under performing and a risk-assessed action plan, with indicative costs and timescales to close the gaps. This, essentially, is the scoring and costing stage of PAM SQA return.

This would include identifying strategy, policy and procedure documents which require updating – in part or in full – to cover the scope of the PAM requirements or adopt current best practice (against statutory requirements where necessary). If not already available, some service benchmarking would be undertaken during this phase to prioritise operational improvements.

For example, this would include reviewing an outsourced catering service specification against nutritional guidance, recommended menu choices and sustainable service delivery. Or, as an estates example, examining water safety policies to confirm compliance with HTM 04-01 that the monitoring and testing regime is appropriate to measure compliance and, finally, that maintenance records and testing results demonstrate compliance.

If any gaps are identified, in the above activities, timely actions and cost estimates to achieve compliance will be produced. Effectively, for the fist time perhaps, an overall cost to deliver an efficient, best practice, organisationally aligned estates & facilities service will be defined.

Gold: Silver service plus Implementation Support

The final stage will be to implement some or all of the above action plans. Our experienced consultants can assist with developing any identified requirements new service strategies, policy and procedure documents, on-site consultancy support to help implement and imbed the changes – which may be more cultural than operational. GK Transformation can also assist where the changes require temporary skills outside the core expertise of the service – such as training, performance measurement, monitoring & comparison and third-party and/or external review services.